The Egyptian Journal of Radiology and Nuclear Medicine (2014) 45, 1021–1028

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology and Nuclear Medicine

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ORIGINAL ARTICLE

Real-time tissue elastography combined

with BIRADS-US classification system
for improving breast lesion evaluation
Fatma Zeinhom Moukhtar a, Amal Amin Abu ElMaati b,*

a
Department of Radio Diagnosis, Cairo University, Egypt
b
Department of Radio Diagnosis, Ain Shams University, Egypt

Received 6 May 2014; accepted 14 May 2014

Available online 14 June 2014

KEYWORDS Abstract Purpose: The purpose of this study was to establish the correlation of prospectively
B-mode ultrasound; interpreted ultrasound elastography (USE) results with American College of Radiology Breast
Real-time tissue Imaging Reporting and Data System (BIRADS) assessment and pathologic diagnoses of sono-
elastography; graphically visible breast masses and to determine whether USE can improve distinction of benign
BIRADS-US; and malignant lesions.
TES Patients and methods: Between April 2012 and January 2014, sonoelastography of focal breast
lesions was carried out in 410 patients with subsequent histological confirmation. We present data
focusing on the sensitivity (SE), specificity (SP) and the positive (PPV) and negative predictive value
(NPV) of sonoelastography. In addition we performed an analysis of the diagnostic performance,
expressed by the pretest and posttest probability of disease (POD), in BI-RADS-US 3 or 4 lesions
as these categories can imply both malignant and benign lesions and a more precise prediction
would be a preferable aim.
Results: Sonoelastography demonstrated an improved SP (89.5%) and an excellent PPV (86.8%)
compared to B-mode ultrasound (76.1% and 77.2%). Especially in dense breasts ACR III–IV, the
SP was even higher (92.8%). In BI-RADS-US 3 lesions, a suspicious elastogram significantly mod-
ified the POD from 8.3% to a posttest POD of 45.5%. In BI-RADS-US 4 lesions, we found a pre-
test POD of 56.6%. The posttest POD changed significantly to 24.2% with a normal elastogram

* Corresponding author. Tel.: +20 1223558198; fax: +20 222687239.

E-mail addresses: amalamin74@yahoo.com, amalaminaa@gmail.com
(A.A.A. ElMaati).
Peer review under responsibility of Egyptian Society of Radiology and
Nuclear Medicine.
0378-603X Ó 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear Medicine.
Open access under CC BY-NC-ND license. http://dx.doi.org/10.1016/j.ejrnm.2014.05.007
1022
and to 81.5% with a suspicious elastogram.
Conclusions: Real-time tissue elastography may provide additional characterization of breast
lesions, improving specificity, particularly for BIRADS 3 and BIRADS 4 lesions.
Ó 2014 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear
1. Introduction
Breast ultrasound elastography (USE) is a new technique of
ultrasonic imaging that has shown effectiveness for detection
of malignancy within breast lesions. USE provides information
about the mechanical properties of tissue such as elasticity and
strain and maps it into color images (1–4). Elasticity is the ten-
dency of a tissue to resume the original size and shape; while
strain is the level of change in size or shape in response to
external compression (stress) (4). Each pixel of the image is
assigned one of 256 specific colors and demonstrates the mag-
nitude of tissue strain depending on physiological and patho-
logical changes in breast structure (3,5). Harder tissues such
as malignancy may result in decreased strain and are shown
in blue, while softer tissues will reflect increased strain and
are shown in red (3). Normal breast tissue which reflects aver-
age strain is shown in green (3). The color image is superim-
posed on B-mode ultrasound (US) image for a better
recognition of the relationship between the strain distribution
and the anatomical borders of the lesion (3,4,6). This informa-
tion is further interpreted by evaluating the color pattern in a
hypoechoic lesion (e.g., within lesion borders on US image),
and in the surrounding breast tissue (3). A 1–5 scale elasticity
score (ES) is assigned to each image based on its overall pat-
tern, with the harder tissues (e.g. breast cancer) showing higher
elasticity scores (3). Although characterization of solid breast
masses by sonography has improved greatly since the early
1990s, specificity remains low, and to date a large number of
breast biopsies result in benign diagnoses. Therefore, any addi-
tional sonographic information to improve lesion characteriza-
tion would help increase specificity. Recently published studies
have reported promising results using elasticity imaging, either
in comparison with B-mode sonography or in conjunction with
the B-mode findings (7–9).
A significant number of false positive and false-negative
findings still occur (10). The consequence of a false-positive
result in diagnostic imaging is the performance of an unneces-
sary biopsy. A false-negative result has an even more serious
implication as the diagnosis of malignancy is delayed, with a
potentially worse clinical outcome for the patient. In order
to prevent excessive biopsies on the one hand and, in particu-
lar, to guarantee the highest level of patient safety on the other
hand, diagnostic methods should be continuously refined.
Today, ultrasound (US) plays a decisive role in the diagnos-
tic pathways, with high sensitivity and specificity (11). Despite
technical advances, the most important step in bringing breast
US to its current position was the introduction of the stan-
dardized BI-RADS-US-classification system by the American
College of Radiology (ACR) (12).
The ACR BI-RADS-US lexicon provides various catego-
ries with predefined terminology to describe the dominant fea-
tures of breast lesions accurately. According to the ACR, each
F.Z. Moukhtar, A.A.A. ElMaati
Medicine. Open access under CC BY-NC-ND license.
lesion should be assigned a BI-RADS-US category ranging
from BI-RADS-US 0 to BI-RADS-US 6 at the end of the diag-
nostic procedure (12). The distinct BI-RADS-US classification
also implies what further clinical action should be taken: BI-
RADS-US 4 lesions are possibly malignant and BI-RADS-
US 5 lesions are probably malignant. Therefore, the appropri-
ate consequence is a biopsy, usually under US guidance.
Malignancy practically never occurs in BI-RADS-US 2
lesions, which are defined as benign findings. To our under-
standing, the group of BI-RADS-US 3 lesions remains a crit-
ical category. These findings are probably benign and short-
term follow-ups are recommended. Nevertheless, malignancy
is eventually diagnosed in about 3% of these lesions, resulting
in a delayed diagnosis of cancer in a considerable number of
patients (13). Therefore, a suitable predictor for malignancy
in BI-RADS -US 3 lesions would be beneficial and of clinical
relevance. Nowadays, newly developed US technologies may
allow a better differentiation of benign and malignant masses
(14).
The goal of our study was to determine the usefulness of
USE in the evaluation of solid masses or indeterminate breast
lesions in a clinical setting with pathology as the reference
standard. Specifically, our aim was to establish the correlation
of prospectively interpreted USE results with American Col-
lege of Radiology Breast Imaging Reporting and Data System
(BIRADS) assessment and pathologic diagnoses of sonograph-
ically visible breast masses and to determine whether USE can
improve distinction of benign and malignant lesions, thereby
increasing specificity and positive predictive value.
The aim of our study is to focus on the application of USE
for further characterization of lesions that are initially catego-
rized as BI-RADS-US 3 or 4 as these categories can imply both
malignant and benign lesions and a more precise prediction of
a lesion’s malignancy status in these categories would be
valuable.
2. Patients and methods
2.1. Patients
We performed 410 ultrasound examinations at a private center
between April 2012 and January 2014. The patients were
referred to the center due to specific diagnostic queries such
as palpable breast lesions, pain, suspicious mammograms,
breast cancer follow-up or intensified screening in high-risk
populations. Patients, who presented a lesion in B-mode ultra-
sound that required the taking of a histological specimen, were
considered to be suitable for the study, and additional elasto-
graphic examination was carried out. Finally the patients were
scheduled to undergo ultrasound-guided core needle biopsy of
the breast lesion. The age of the patients ranged from 18 to
72 years (mean, 42.6 years).
Real-time tissue elastography for breast lesion evaluation
2.2. Ultrasound examinations and biopsy procedures
Ultrasound and elastography images were obtained by using a
6–14 MHz linear array transducer (Toshiba Aplio XG ultra-
sound machine). Real-time whole breast ultrasound examina-
tion was performed by an experienced radiologist (with
10 years of experience in breast imaging).
After the whole breast ultrasound examination, ultrasound
and elastography were performed sequentially only at the
lesion subjected to biopsy. In order to make the images compa-
rable to each other and to perform the analysis, each elasto-
gram had to include a complete sectional plane of the tumor
as well as an adequate (more than approximately 50% of the
area) amount of surrounding normal breast tissue.
Biopsy was performed by the same radiologist who per-
formed the whole breast ultrasound examination. Local anes-
thesia (1% lidocaine) was routinely applied, and an automated
gun (Pro-Mag 2.2, Manan Medical Products) and a 14-gauge
True Cut needle with a 22-mm throw (SACN Biopsy Needle,
Medical Device Technologies) were used. Informed patient
consent was obtained for all biopsy procedures.
2.3. Real-time ultrasound elastography
Ultrasound elastography was performed using a freehand
technique at the same time as ultrasound. Images were
obtained by applying repetitive light compression at the skin
above the targeted breast lesion. The probe was positioned
perpendicular to the skin when applying pressure. The ultra-
sound scanner was equipped with an elastography unit, images
were presented in a split-screen mode with the conventional
images on the right, and the translucent color-scale elastogra-
phy images were superimposed on the corresponding ultra-
sound image on the left. A square region of interest (ROI)
was set for elastography acquisition; the superior margin was
set to include subcutaneous fat, the inferior margin was set
to include pectoral muscle, and the lateral margin was set to
include more than 5 mm of breast parenchyma adjacent to
the targeted lesion.
2.4. Image interpretation and data management
For each patient the B-mode ultrasound pictures were catego-
rized according to the Breast Imaging Reporting and Data
System criteria of the American College of Radiology (ACR
BIRADS-US) (12).
The elastograms were evaluated using the Tsukuba Elastic-
ity Score, a 5-point strain scale partly corresponding to the BI-
RADS classification (Fig. 1).
So far sensitivity and specificity are the highest when a score
between 3 and 4 is established as the cut-off point for the
malignancy (3). Therefore, lesions that are categorized as score
1 and score 2 are considered benign, and lesions categorized as
score 4 and 5 are suspicious or highly suspicious for cancer.
Lesions categorized as score 3 remain particularly unclear,
but are more likely to be benign.
Score 1: strain appears in the entire hypoechoic area (the
entire lesion is shown in green as in the surrounding normal
breast).
1023
Score 2: strain is not seen in part of the hypoechoic area
(the lesion is shown as a mosaic of green and blue).
Score 3: strain appears only in the peripheral areas and not
in the center of the hypoechoic area (the center of the lesion
is shown in blue while the peripheral areas in green).
Score 4: no strain appears in the entire hypoechoic area (the
entire lesion appears in blue).
Score 5: no strain appears either in the hypoechoic area or
in surrounding areas (the lesion and surrounding areas are
shown in blue).
2.5. Statistical analysis
We used the statistical software package SPSS 17.0 (Chicago,
IL, USA). In order to assess the accuracy of real-time tissue
elastography compared with the histological results. The diag-
nostic sensitivity, specificity and positive and negative predic-
tive values as well as the pretest and posttest probability of
disease were calculated based on the specimen histology as
the gold standard using Fisher’s exact test. A separate analysis
with respect to BI-RADS-US 3 and 4 tumors was performed.
3. Results
All 410 cases were histologically evaluated. Specimen histology
demonstrated 196 malignant and 214 benign lesions. The his-
tological results are summarized in Table 1. The average diam-
eter of benign tumors was 15.8 ± 10.2 mm and 17.0 ± 9.2 mm
of malignant tumors. The size difference was not significant
(p > 0.05).
Using B-mode ultrasound for the 214 benign lesions, 163
were correctly identified, while 51 of these lesions were incor-
rectly classified as BI-RADS-US 4 or 5. Using USE, 192 of
the 214 lesions were correctly classified. Regarding the malig-
nant lesions, B-mode ultrasound yielded a correct classification
of BI-RADS-US 4 or 5 in 186 of 196 cases. USE identified 146
lesions as malignant, but the remaining 50 lesions showed a
normal elastogram.
The resulting sensitivity for conventional B-mode ultra-
sound was 95.0% and significantly higher than the sensitivity
for USE that was 81.2%. Regarding the specificity, USE
yielded the best result with 89.5%, which was significantly
higher than the specificity in B-mode ultrasound (76.1%).
The positive predictive value was high for USE (86.8%) and
thus significantly higher than in conventional ultrasound,
which showed a positive predictive value of 77.2%. B-mode
ultrasound had the best negative predictive value of 94.7%,
which was significantly higher than the negative predictive
value of USE (84.8%). The results are summarized in Table 2.
3.1. Impact of evaluating BI-RADS-US 3 lesions with
sonoelastography
Regarding the 95 lesions that were classified BI-RADS-US 3 in
conventional ultrasound, we obtained the following results:
The pretest probability of disease in these cases was 8.3%
and rose significantly to 45.5% with an abnormal elastogram
(Tsukuba Elasticity Score 4 or 5). The posttest probability of
disease with a normal elastogram (Tsukuba Elasticity Score
1 to 3) was only 3.1%, although this difference was not signif-
icant. The results are summarized in Table 3.
1024 F.Z. Moukhtar, A.A.A. ElMaati

Fig. 1 Breast elastography images are divided into the following five imaging patterns (Tsukuba Elasticity Score) compared with the B-
mode hypoechoic lesions.

3.2. Impact of evaluating BI-RADS-US 4 lesions with

Table 1 Final pathologic diagnoses in 410 breast lesions.
sonoelastography
Malignant lesions (196)
Invasive ductal carcinoma 136
Invasive lobular carcinoma 33 We performed the identical test as for the BI-RADS-US 3
Other invasive carcinoma 20 lesions with respect to the BI-RADS-US 4 lesions (n = 112).
Ductal carcinoma in situ 7 For these lesions we found an initial probability of disease of
56.6%, which rose significantly to 81.5% after a positive test,
Benign lesions (214)
meaning a suspicious elastogram (Tsukuba Elasticity Score 4
Cyst 62
Fibroadenoma 60 or 5). The posttest probability of disease with a normal elasto-
Fibrosis 21 gram (Tsukuba Elasticity Score 1–3) was 24.2% and therefore
Fibrocystic mastopathy 22 significantly lower. The results are summarized in Table 4.
Mastitis 8
Papilloma 4 3.3. Evaluating the accuracy of sonoelastography with respect to
Other benign 37 the density of the breast

We found no significant differences regarding the sensitivity

and the positive predictive value, which were 84.2% and
Table 2 Comparison of sensitivity, specificity, positive (PPV) 89.6% in dense breasts ACR III-IV and 84.4% and 91.0%
and negative predictive value (NPV) for B-mode ultrasound in in less dense breasts ACR I-II.
the differentiation of benign lesions from malignant breast There was a trend toward a higher specificity in dense
cancer. 95% confidence interval in brackets. breasts (92.8%) compared with ACR I-II breasts (82.7%)
B-mode ultrasound Sonoelastography although this difference was not significant. The negative pre-
Sensitivity 95.0 (92.0–97.0) 81.2 (76.7–85.1) dictive value was significantly higher in dense breasts (88.8%)
Specificity 76.1 (71.7–80.1) 89.5 (86.1–92.2) than in less dense breasts (72.0%). The results are summarized
PPV 77.2 (73.0–81.0) 86.8 (82.6–90.2) in Table 5.
NPV 94.7 (91.5–96.7) 84.8 (81.1–88.0) Five case examples are presented. Fig. 2 shows a partially
mottled low echo on USG lesion with TES of 4. Biopsy
Real-time tissue elastography for breast lesion evaluation 1025

Table 3 Comparison of pretest and posttest probability of disease (POD) within the subgroup of BI-RADS-US 3 lesions. 95%
confidence interval in brackets.
Tsukuba Elasticity Score 1–3 (test negative) Tsukuba Elasticity Score 4–5 (test positive)
Pretest POD 8.3 (4.9–13.6)
Posttest POD 3.1 (1.1–7.6) 45.5 (25.1–67.3)

Table 4 Comparison of pretest and posttest probability of disease (POD) within the subgroup of BI-RADS-US 4 lesions. 95%
confidence interval in brackets.
Tsukuba Elasticity Score 1–3 (test negative) Tsukuba Elasticity Score 4–5 (test positive)
Pretest POD 56.6 (49.8–63.2)
Posttest POD 24.2 (16.3–34.3) 81.5 (73.3–87.7)

4. Discussion
Table 5 Comparison of sensitivity, specificity and positive
(PPV) and negative predictive value (NPV) for sonoelastogra-
phy with respect to the density of the breast. 95% confidence Elasticity imaging is based on the premise that there is an
interval in brackets. inherent difference in the pliability of normal versus diseased
tissue, and this difference can be measured as strain (displace-
ACR I–II ACR III–IV
ment or elongation of tissue during manual compression) and
Sensitivity 84.4 (77.8–89.4) 84.2 (76.6–89.7) displayed in real time during sonographic imaging (15). The
Specificity 82.7 (72.4–90.0) 92.81 (87.7–95.9) first dynamic tests using real-time ultrasound to assess the
PPV 91.0 (85.0–94.8) 89.6 (82.6–94.1) compressibility of breast masses were introduced in the 1980s
NPV 72.0 (61.6–80.6) 88.82 (83.2–92.8)
and have been used ever since (16). Over the years sonoelastog-
raphy has evolved gradually from a relatively complicated
method involving large and cumbersome hardware and com-
plicated examination set-ups (18,19) to an elegant ultrasound-
result was ductal carcinoma in situ. Fig. 3 shows ductal car- based technique. Real-time tissue elastography as it is available
cinoma in situ, diagnosed after repetition of pathology, as today is a dynamic method, which is mainly used for the eval-
its TES was 5. Fig. 4 shows a sclerosing adenosis lesion with uation of lesions in breast, prostate or thyroid tissue, axillary
a TES of 3. Fig. 5 shows a case of encephaloid carcinoma and mediastinal lymph nodes and for the assessment of force
with a TES of 4. Lastly, Fig. 6 illustrates an in situ ductal generation in skeletal muscle (17–19).
carcinoma with an invasive component that was interpreted The sensitivity in our study for B-mode ultrasound, regard-
on US as benign sclerosing adenosis lesion, yet with a TES ing all BI-RADS-US categories, was 95% and the specificity
of 4. (76.1%) was rather poor, but this was increased up to 89.5%

Fig. 2 B-mode US image (A) and USE image (B) performed in a patient with fibrocystic dysplasia. The B-mode picture (A) exhibits the
features of a BI-RADS-US 3 lesion. The elastogram (B) shows no strain over the entire lesion and was categorized Tsukuba Elasticity
Score 4. Pathology showed in situ ductal carcinoma.
1026 F.Z. Moukhtar, A.A.A. ElMaati

Fig. 3 (A) B-mode US image and (B) USE image performed in a patient with fibrocystic dysplasia revealed a hypoechoic lesion with
irregular boundaries exhibiting the features of a BI-RADS-US 4 lesion. Tsukuba Elasticity Score was 5. Pathology revealed localized
adenosis yet considering the TES of 5 wire localization and excisional biopsy was recommended that revealed in situ ductal carcinoma.

Fig. 4 (A) B-mode US image and (B) USE image reveal an ill defined hypoechoic lesion exhibiting the features of a BI-RADS-US 4
lesion, yet with a Tsukuba Elasticity Score of 3, suggestive of a benign lesion. Biopsy results revealed sclerosing adenosis.

by the use of realtime elastography. The results are compara-
ble to those of Sadigh et al. (20) in a recent meta-analysis
regarding all BI-RADS-US categories, where real time elastog-
raphy demonstrated a sensitivity of 79% and an excellent spec-
ificity of 88% compared to conventional B-mode US (96% and
70%, respectively).
There are certain situations in which patients almost never
receive a single imaging technique alone (i.e. conventional
ultrasound, mammography or magnetic resonance imaging),
but usually undergo several different examinations before
receiving a final diagnosis. Therefore, in a realistic setting,
sonoelastography is not applied as a single method but is used
in addition to other examinations in ‘‘heavily pre-diagnosed
patients’’ (21).
An elastogram, for example, might be capable of identify-
ing a breast lesion as highly suggestive of malignancy, but if
this lesion was already suspicious on the mammogram (i.e.
BI-RADS 5) and/or in the conventional ultrasound (i.e. BI-
RADS-US 5), this additional information would not have an
effect on the management of the patient (21).
Therefore, we need to concentrate on patients and breast
lesions where the appropriate action is as yet unclear and a
more advanced assessment is needed. This is the rationale
for our focus on patients with BI-RADS - US 3 and BI-RADS
- US 4 lesions. Regarding BI-RADS - US 3 lesions the risk for
malignancy is relatively low in this category, but can reach 3%
or even more in distinct patient populations (22,13,23).
Our results demonstrate that the majority (91.7%) of BI-
RADS-US 3 lesions are in fact benign. In those cases, which
additionally showed a normal elastogram (Tsukuba Elasticity
Score 1–3), the new negative predictive value was even higher
by trend (96.9%). However, as soon as there was a suspicious
elastogram, the risk for a malignant tumor increased
significantly from 8.3% to a posttest probability of disease of
45.5%. Our results agreed with a recent study done by
Wojcinski et al. (21) who were concerned with patients with
Real-time tissue elastography for breast lesion evaluation 1027

Fig. 5 (A) B-mode US image and (B) USE image showed a hypoechoic circumscribed lesion exhibiting the features of a BI-RADS-US 3
lesion, displaying a mosaic pattern of green and blue but because the blue area is clearly larger the elasticity score was determined to be 4.
Biopsy revealed encephaloid carcinoma.

Fig. 6 (A) B-mode US image and (B) USE image revealed a small, hypoechoic rather ill defined lesion which was interpreted as
sclerosing adenosis, with a Tsukuba Elasticity Score of 4. Pathology revealed in situ ductal carcinoma with invasive component.

a sonographically visible lesion categorized as BI-RADS-US 3.
They demonstrated that the pretest POD was 4.5% and rose
significantly to 13.2% with a suspicious elastogram in the
high-risk group.
If biopsy would be taken in these cases, we can estimate a
maximal malignant/benign ratio of 1:3, which means that we
can expect at least 1 carcinoma per 4 biopsies. Regarding the
high posttest probability of disease, we encourage immediate
histological verification of BI-RADS-US 3 lesions exhibiting
a suspicious elastogram (Tsukuba Elasticity Score 4 or 5).
Lesions in BI-RADS US 4 category require histological
verification. If there is no evidence of malignancy in specimen
histology, no further steps are required. This approach impli-
cates the risks that are associated with a false negative biopsy.
The pretest probability of disease for BI-RADS-US 4 lesions
in our study was 56.6%. Our results showed a significantly
reduced posttest probability of disease of 24.2% for BI-
RADS-US 4 lesions with a normal elastogram (Tsukuba Elas-
ticity Score 1–3) and a significantly increased risk of 81.5% for
lesions with a suspicious elastogram (Tsukuba Elasticity Score
4 or 5). Regarding the still high probability of disease after a
normal elastogram, there should be no change in the clinical
procedure in those cases. On the other hand, a suspicious elas-
togram indicates a highly increased risk for a malignant dis-
ease. Therefore, we suggest re-biopsy whenever there is a BI-
RADS-US 4 lesion with a suspicious elastogram (Tsukuba
Elasticity Score 4 or 5) but the specimen histology shows no
malignancy since a false negative histological result is a possi-
ble scenario.
When comparing the results for sonoelastography with
respect to the density of the breast, we found no difference
regarding the identification of malignant lesions, but the nega-
tive predictive value and the specificity were higher in the ACR
III–IV breasts than in ACR I–II breasts. This observation can
be explained by the mechanical principles of sonoelastography:
Real-time tissue elastography provides a relative measurement
1028
of the elasticity of the tissue by comparing the different struc-
tures within the region of interest. So far, an absolute measure-
ment is not available. Benign lesions usually present soft in
sonoelastography. As the measurement of the lesion is only
performed in relation to the surrounding tissue, even a benign
lesion might appear relatively hard, if the adjacent tissue is rel-
atively soft (24). Our results in this aspect agree with the model
of an ‘‘elastographic contrast’’ that has been described by Woj-
cinski et al. (25) who stated that the ‘‘elastographic contrast’’
for benign lesions seems to be better in hard, which means
dense, breast tissue. Consequently, the correct identification
of benign lesions in a less dense breast seems to be more diffi-
cult with sonoelastography.
5. Conclusion
Our study demonstrates that there are no data that indicate a
clinical advantage for the additional sonoelastographic evalu-
ation of lesions that are categorized BI-RADS-US 0, 1, 2 or
5 in conventional ultrasound. However, for lesions that are
categorized BI-RADS-US 3 or 4 in B-mode ultrasound our
data provide evidence that an improved diagnostic perfor-
mance can be achieved by adding real-time tissue elastography.
Conflict of interest
We have no conflict of interest to declare.
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